Inspection visit

InspectionJune 8, 2023

SPRINGS ROAD HEALTHCARECMS #05522211 citations on this visit

11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. Review of the admission Record indicated, Resident 34 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome. During a concurrent observation and interview with Resident 34 on 6/5/23 8:40 AM, a white oblong pill sitting on a plastic spoon was on a table next to Resident 34's bed. When asked about the pill, Resident 34 stated, That's my Percocet! (opiate/narcotic pain medication) and immediately picked up the pill, put it in his mouth, and swallowed it. Resident 34 stated the night shift nurse, Licensed Vocational Nurse 5 (LVN 5) brought him the Percocet a few hours prior. Resident 34 reported, Sometimes they watch me swallow the pills but sometimes they don't, and I can keep it for later. During a concurrent interview and record review with (LVN 2) on 6/5/23 at 9:44 AM, Resident 34's Medication Administration Record was reviewed. LVN 5 documented he administered Percocet to Resident 34 on 6/5/23 at 5:54 AM. Resident 34's Percocet supply was observed with LVN 2. LVN 2 confirmed Percocet were white oblong pills. During an interview with on 6/8/23 at 7:30 AM, LVN 5 stated Resident 34 was knowledgeable about his medications and could identify which pill was Percocet. LN 5 confirmed he administered Percocet to Resident 34 on 6/5/23 at 5:54 AM, but denied he left the medication at the bedside. LVN 5 further denied noticing an unsecured white pill sitting on Resident 34's table during his shift. During an interview with the Director of Nursing (DON) on 6/8/23 at 8:15 AM, the DON stated it was unacceptable for nursing staff to leave medications unsecured at the resident's bedside, especially controlled medication. The DON stated it was very concerning that Resident 34 reported nursing staff did not always observe him consume his Percocet, because staff needed to know the exact time the medication was consumed. The DON stated, If the resident is saving them for later, there is opportunity for overdose. During a review of Resident 34's Minimum Data Set (resident assessment tool), dated 3/29/23, Resident 34's Brief Mental Status score was 15, which indicated Resident 34 was cognitively intact. During a review of Resident 34's physician's order, dated 4/21/22, indicated Resident 34 could receive one Percocet 10 mg (milligrams)/350 mg Tylenol tablet every four hours as needed. Review of the facility's policy titled, Controlled Medication Storage, dated 2007, indicated, . Only authorized licensed nursing and pharmacy personnel have access to controlled medications . (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 055222 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide a safe environment for 3 of 17 sampled residents (Residents 25, 34, and 45). a. For Resident 25, two unlabeled cups, containing medication pills, were left unattended on the bedside table. Residents Affected - Few b. For Resident 34, a white oblong pill was left on a plastic spoon unattended on the table. c. For Resident 45, Certified Nurse Assistant 1 (CNA 1) and Certified Nurse Assistant 2 (CNA 2) failed to lower the bed to its lowest position after they completed personal care to Resident 45. These failures had the potential to cause serious bodily injuries, and unauthorized access to narcotics (to treat moderate and severe pain) and medications to Residents in the facility. Findings: a. Review of the admission Record indicated, Resident 25 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder, current episode mixed, severe, without psychotic features (changes in a person's mood, energy, and ability to function) and Type 2 Diabetes Mellitus with unspecified complications (a problem in the way the body regulates and uses sugar as fuel). Review of Resident 25's active physician order summary as of 6/5/23, indicated the following medications: 1. Order dated 3/24/23, metformin (for type 2 Diabetes Mellitus) extended release (the medication is released slowly over time) twenty-four hour 500 milligram (mg) give 4 tablets by mouth one time a day. 2. Order dated 3/24/23, Allupurinol (for protein in the urine) 300 milligram (mg) give one tablet by mouth one time a day. 3. Order dated 3/24/23, ezetimibe (for elevated cholesterol levels) tablet 10 milligram (mg) give one tablet by mouth one time a day. 4. Order dated 3/24/23, cyanocobalamin (for vitamin B12 deficiency) tablet 1000 microgram (mcg) by mouth one time a day for supplement. 5. Order dated 3/24/23, fenofibrate (to lower high cholesterol levels) 160 milligram (mg) by mouth one time a day. 6. Order dated 3/24/23, lamotrigine (for shaking and bipolar disorder) 25 milligram (mg) give one tablet by mouth one time a day. 7. Order dated 3/24/23, Losartan potassium (for high blood pressure) 100 milligram (mg) give one tablet by mouth one time a day. 8. Order dated 3/24/23, venlafaxine (for anxiety) extended release twenty-four hour 75 milligram (mg) give one tablet by mouth one time a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation of Resident 25's room on 6/5/23 at 9:35 AM, two unlabeled medication cups containing eight medication pills, were left unattended on Resident 25's bedside table. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/5/23 at 9:38 AM, LVN 1 confirmed she left the two cups of medication pills on Resident 25's bedside table, unattended for thirty minutes. LVN 1 also stated she did not wait for Resident 25 to consume metformin 500 mg, Allupurinol 300 mg, ezetimibe 10 mg, cyanocobalamin 1000 mcg, fenobibrate 160 mg, lamotrigine 25 mg, Losartan potassium 100 mg, and venlafaxine 75 mg. During an interview with the Director of Nursing (DON) on 6/5/23 at 9:45 AM, the DON confirmed Resident 25 did not have a nursing care plan for self-administration of medications. The facility's policy and procedure, titled, Administering Medications, revised April 2019, indicated, Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions and honoring resident choices and preferences, consistent with his or her care plan. Resident may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they have the decision-making capacity to do so safely . c. During an observation on 6/6/23 at 8:25 AM, Resident 45 was receiving personal care by CNA 1 and CNA 2. Following the care, the two CNA's left the room. Resident 45's bed was elevated in the highest position, several feet off the floor. During a concurrent observation and interview on 6/6/23 at 8:28 AM, with CNA 1, CNA 1 stated sometimes the residents will accidentally use the button and raise the bed by themselves, and stated Resident 45 could have raised it herself and then referred me to speak with CNA 2. CNA 1 lowered Resident 45's bed back to the lowest position when prompted. During an interview on 6/7/23 at 8:40 AM, CNA 2 stated when she CNA 1 left the room following providing care on 6/6/23, they must have forgotten and did not return Resident 45's bed to the lowest position as they should have. During a review of Resident 45's Care Plan, dated 5/15/23, the Care Plan indicated Resident 45 had a fall risk assessment of 12, with 10 or above being high risk. The Care Plan indicated the environment would be kept free of hazards by facility staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for the care and maintenance of a PICC (Peripherally Inserted Central Catheter) (a long catheter that is inserted through the skin into a large vein just above the heart used for administering antibiotics or fluid) for one of 17 sampled residents (Resident 28). As a result of this failure, Resident 28 was at risk for infection and complications from his PICC. Findings: Review of the admission Record indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses which included sepsis (blood infection) and pressure ulcers, and Resident 28 required intravenous (IV) antibiotics (medication given through a vein to treat infection). During a concurrent observation and interview with Resident 28 on 6/6/23 at 8 AM, Resident 28 stated he had a PICC for IV antibiotics, which were discontinued approximately two weeks prior. Resident 28 reported the hub (essential part of the catheter where a syringe or medication tubing would connect) of the PICC broke off two days after the antibiotics were discontinued, and a nurse coiled the tubing and placed a dressing over the tubing. Resident 28 stated, No one has done anything with it since, and I am waiting to have it removed. Resident 28 stated he was concerned he was at risk for infection due to the broken PICC. A catheter was observed in Resident 28's right upper chest. There was no hub at the end of the catheter tubing; instead, the catheter end was exposed. The entire length of the exposed catheter tubing was coiled, and a clear tape dressing was placed on top. The dressing was not dated to indicate when it was changed. During an interview with Registered Nurse 3 (RN 3), who was the charge nurse, on 6/6/23 at 1:42 PM, RN 3 stated she was unaware of any issues with Resident 28's PICC. She stated Resident 28 was waiting for a physician's appointment to have the PICC removed. RN 3 stated the PICC dressing should have been changed weekly and flushed per order. RN 3 stated she had just observed Resident 28's PICC and confirmed the hub was broken off and the dressing was not dated. She stated, I'm not sure how long it's been like that, but the resident says it's been a long time. RN 3 stated she was unaware if the physician was notified the PICC was broken. During a concurrent interview and review of Resident 28's record with the Director of Nursing (DON) on 6/8/23 at 8:15 AM: The physician's order, dated 3/18/23, indicated Resident 28 had a PICC in his right upper chest. The order directed staff to change the PICC dressing and hub every Sunday and monitor the insertion site for signs and symptoms of infection. The Minimum Data Set, dated [DATE], indicated Resident 28's Brief Mental Status score was 15 (which indicated Resident 28 was cognitively intact). The physician's order, dated 5/24/23, indicated Resident 28's antibiotics were discontinued. Nursing Notes on 5/7/23 and 5/14/23, indicated nursing staff changed Resident 28's PICC dressing. There was no documentation which indicated the PICC had been assessed or the PICC dressing was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 changed, on 5/21/23, 5/28/23, or 6/4/23. Level of Harm - Minimal harm or potential for actual harm The DON stated she was unaware of any issues with Resident 28's PICC until it was identified during the survey. The DON confirmed there was no documentation of assessments or dressing changes for Resident 28's PICC after 5/14/23, no documentation which indicated the PICC hub was broken, and no documentation the physician was notified. The DON stated the broken PICC placed Resident 28 at risk for bleeding and infection, and staff should have notified her and the physician when the line broke and documented the notification. Residents Affected - Few Review of the facility's policy titled, Central and Midline Dressing Changes, undated, indicated, The following information should be recorded in the resident's medical record: Date and time the dressing was changed . any complications, interventions that were done . Report any signs and symptoms of complications to the provider, supervisor, and oncoming shift . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were in stock and available to administer, for one unsampled resident (Resident 250). As a result of this failure, Resident 250 was at risk for potential complications of not receiving medications timely. Findings: Review of the admission Record indicated Resident 250 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection and colonic polyps (abnormal growths in the lining of the colon). During an observation of medication pass with Licensed Vocational Nurse 2 (LVN 2) on 6/7/23 at 8:05 AM, LVN 2 prepared Resident 250's morning medications. LVN 2 confirmed she was administering five medications to Resident 250 during the medication pass. Review of Resident 250's medication orders on 6/7/23 at 12 PM, indicated Resident 250 should have received six medications during the medication pass. LVN 2 did not administer Colace 250 mg (milligram) gel capsule (an over-the-counter stool softener) during the medication pass observation. During an interview with LVN 2 on 6/7/23 at 12:10 PM, LVN 2 stated Resident 250's Colace was not available to administer, and she sent a message to pharmacy to refill the medication. LVN 2 confirmed the medication was due at 9 am, and Resident 250 had not received Colace at the time of the interview. LVN 2 stated she did not notify the physician the medication was not available and was late. During an observation of the central supply closet with the Infection Preventionist (IP 1) and the Administrator on 6/7/23 at 2 PM, the over-the-counter medication supply was noted. There were no Colace 250 mg gel capsules in the supply. During an interview on 6/8/23 at 1:34 PM LVN 1 stated there should be at least a seven-day supply of medication for every resident. LVN 1 stated, every Friday the med nurse should check the cart for low supply and make sure medications are ordered if supply is low. LVN 1 stated, over-the-counter medications were stored in the central supply closet and, if a medication was not available in the supply closet, staff should notify the Director of Nursing so she could purchase the medication. LVN 1 stated this process was not documented, and no inventory was kept of over-the-counter medications in the medication carts. During a review of Resident 250's physician's orders, dated 5/31/23 at 4:43 PM, the order indicated Resident 250 should receive Colace 250 mg capsule once daily. During a review of the facility's medication administration schedule, dated 2/6/23, daily medications should be administered at 9 AM. The facility did not provide a policy related to the inventory and supply of over-the-counter medications during the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide food at an appetizing temperature for 3 of 17 sampled residents (Resident 9, Resident 28, Resident 100) and one unsampled resident (Resident 10). This failure resulted in residents' dissatisfaction with their meals and the potential to decrease the amount of food consumed by residents, therefore reducing nutritional support aiding in recovery from illness or injury. Residents Affected - Few Findings: During an interview with Resident 100 on 6/5/23 at 8:30 AM, Resident 100 stated, food is cold .and they don't do anything about it. During an interview with Resident 9 on 6/8/23 at 7:33 AM, Resident 9 stated his food is always cold by the time he got to eat. During an observation with Food Service Manager 1 (FSM 1) on 6/8/23 at 7:35 AM, FSM 1 validated the temperature of Resident 9's breakfast following delivery to Resident 9's room. The waffle was 82 degrees, and the hot cereal was 93 degrees. During an observation on 6/8/23 at 7:45 AM, Resident 10's eggs were verified by FSM 1 to be 97.6 degrees on the food rack prior to delivery to Resident 10. During an observation on 6/8/23 at 7:50 AM, FSM 1 verified Resident 28's waffle was 100.6 degrees, and the eggs were 100.1 degrees once the tray arrived in his room. During an interview on 6/8/2023 at 7:51 AM, FSM 1 stated the food should arrive at the residents' room at 120 degrees or higher. During an interview with Resident 100 on 6/8/23 at approximately 8:30 AM, Resident 100 stated, I do not know how they transport it here, but it is always cold. During an observation on 6/8/23 at 11:55 AM, FSM 1 verified the temperature of the cheeseburger for Resident 28, it was 112.5 while on the tray rack prior to distribution to Resident 28. At 11:57 AM, the cheeseburger for Resident 100, on the tray rack, was verified by FSM 1 to be 104 degrees. During an interview with resident 100 on 6/8/23 at 11:58 AM, Resident 100 stated his cheeseburger was not cold, just adequate. During a review of the facility's policy and procedure titled, Food Temperature, dated 10/17, indicated, .hot foods should be 140 degrees or above while on tray line . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to keep the kitchen and equipment clean, free from residual food build up and grime. This failure resulted in unsanitary work areas where pathogens could potentially affect the residents with food-borne illness. Findings: During an observation on 6/8/23 at 7:05 AM, in the facility kitchen, many surfaces and equipment had the discoloration of food build-up and grime in various locations. Photographs were taken to capture the soilage. Areas noted were: An electrical socket located behind the toaster, the facial surface of the blender, the toaster, the steamer door, inside and out, the scale, a bracket fixated on the doorframe of the door to the parking lot, the dishwasher, signage, the can opener's base and the door frame to the food service office. During a concurrent interview and observation on 6/8/23 at 9:00 AM with Food Service Manager 1 (FSM 1), in the kitchen, the FSM 1 verified the presence of the discoloration from food build-up and grime at the various locations observed. The FSM 1 stated his staff should do a more thorough job, and the grime and residual food was not washed well with the daily wipes currently being done. During a review of the kitchen's Daily Cleaning Schedule, dated June 2023, the Daily Cleaning Schedule indicated the staff signed off on daily cleaning with multiple tasks. Evidence of soilage present indicated cleaning tasks were not completed effectively. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide evidence of annual tuberculin skin test (a test to determine the presence of infection with tuberculosis and bacterial infection of the lungs) results for Infection Preventionist 1(IP 1). This failure had the potential to spread undetected Tuberculosis (TB) infection (spread through the air from one person to another when a person with TB coughs and speaks) to a universe of 55 Residents in the facility. Residents Affected - Few Findings: During a review of IP 1's personal file, indicated, Quantiferon-TB Gold Plus test (tests for TB infection) results were done on 3/20/22. During an interview with the Director of Staff Development (DSD) on 6/8/23 at 9:45 AM, the DSD confirmed the IP 1 did not have an updated purified protein derivative (PPD-to help diagnose tuberculosis infection) skin test for TB. During an interview with Director of Nursing (DON) on 6/8/23 at 10:39 AM, the DON stated the IP 1's tuberculin skin test should have been updated and done annually. The facility's policy and procedure, titled, Employee Tuberculosis Screening, updated September 2019, indicated, The individual State mandates annual testing by law . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055222 If continuation sheet Page 9 of 9

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Citations

11 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0726GeneralS&S Dpotential for harm
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0804GeneralS&S Dpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0812GeneralS&S Dpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
0920GeneralS&S Dpotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

FAQ · About this visit

Common questions about this visit

What happened during the June 8, 2023 survey of SPRINGS ROAD HEALTHCARE?

This was a inspection survey of SPRINGS ROAD HEALTHCARE on June 8, 2023. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SPRINGS ROAD HEALTHCARE on June 8, 2023?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·June 8, 2023